Survey | Qualtrics Survey Software

Your contact information.

First Name
Last Name
Email Address
Attending College/University

Your Campus Address & Phone Number (if you reside on campus).

Your Home Address & Phone Number.

What is your Student Status?

What is your Credit Status?

What is your Ethnicity?

What is your Gender?

What is your Primary Disability?

Are you registered with the NJ Commission for the Blind?

Are your registered with the Division of Vocational Rehabilitation?

What semester will you be borrowing the equipment?

What is the Platform of your computer?

List the Software you would like to borrow.

List the Hardware you need to borrow.

Provide the contact information for the Disability Support Coordinator at your College/University.

Borrowing equipment from the Adaptive Technology Center for New Jersey Colleges requires that you agree to the following Terms of Responsibility:

a. I will return the items borrowed in the same physical condition as I received them;

b. I will return the items borrowed at the conclusion of the current academic semester;

c. If the item I borrowed was software, I will uninstall it at the conclusion of the academic semester;

d. I understand that copying software is illegal and punishable in a court of law.

What is today's date?

Month/Date/Year